In Lagos and Abia states, malaria tests cost as much or more than the actual treatment, creating a dangerous pricing dilemma that pushes millions of Nigerians to skip testing and self-medicate with potentially deadly consequences.
Here is the thing: Aliyu walks into a pharmacy in Surulere, Lagos, feeling feverish and weak. The pharmacist offers him two options, take a malaria test for ₦2,500 or buy antimalarial drugs for ₦2,000. He chooses the drugs, after all, he reasons, why spend more to confirm what he already suspects?
This calculation plays out thousands of times daily across Lagos and Abia states, where a recent ACTwatch Lite Nigeria 2024 study revealed a troubling reality. Rapid Diagnostic Tests (RDTs) for malaria are priced as high or higher than Artemisinin-based Combination Therapies (ACTs), the recommended treatment for confirmed malaria cases.
The pricing structure creates distorted motivations throughout the healthcare system. Patients skip testing to save money mostly due to the increasingly economic hardship in the country. On their part, providers stock fewer diagnostic tools because customers prefer cheaper options. The result is widespread presumptive treatment where anyone with a fever receives antimalarials whether they have malaria or not.
The consequences extend far beyond wasted money on unnecessary drugs. When people take antimalarials without confirmed malaria, they risk several problems. First, if their illness is not malaria, the real cause goes untreated while they consume drugs they do not need.
Second, unnecessary antimalarial use contributes to drug resistance, where malaria parasites evolve to survive treatment. Drug resistance represents one of the most serious threats to malaria control globally. The parasites that cause malaria are remarkably adaptable. When exposed repeatedly to antimalarial drugs, some develop resistance and survive. These resistant parasites then multiply and spread over time once effective treatments stop working.
This process has already occurred with older antimalarials like chloroquine and sulfadoxine-pyrimethamine. Nigeria abandoned these drugs after widespread resistance made them ineffective. Now the country relies primarily on ACTs, but protecting these newer drugs requires careful use. Every unnecessary dose increases the risk of resistance developing.
The World Health Organization (WHO) strongly recommends testing before treatment for precisely this reason. Confirmed diagnosis ensures people with malaria get appropriate treatment while those without malaria do not take unnecessary antimalarials. This “test and treat” approach protects both individual patients and the effectiveness of antimalarial drugs for everyone.
Yet the pricing forces in Lagos and Abia states undermine this approach. When testing costs ₦2,500 but treatment costs ₦2,000, patients face an impossible choice. Many lack the extra ₦500 for proper diagnosis, especially when they need to buy drugs anyway. Others simply cannot see the logic in spending more to confirm what seems obvious.
Healthcare providers also face their own calculations. Stocking RDTs requires upfront investment and cold chain storage for some test types. If customers consistently choose to skip testing, vendors have little incentive to maintain diagnostic supplies. This creates a cycle where tests become less available, making presumptive treatment even more common.
The contrast with Kano State makes the problem even clearer. According to ACTwatch Lite Nigeria 2024 study, In Kano, diagnostics cost less than half the price of ACTs. This pricing structure possibly encourages testing before treatment in Kano. Patients feel the financial logic aligns with good medical practice, and they can afford to confirm their diagnosis and still have money for treatment if needed. The regional pricing variation raises important questions. Why do diagnostics cost so much more in Lagos and Abia? Several factors likely contribute; higher operating costs in southern states affect all products and services, supply chain complexities may add costs, and lack of subsidies or price controls for diagnostics leaves them subject to market forces.
Whatever the causes, the effects are clear. The ACTwatch Lite study found an apparent disconnect between antimalarial availability and malaria testing in Abia and Lagos states. While antimalarials flow freely through Patent and Proprietary Medicine Vendors (PPMVs) across these states, testing remains uncommon in these same outlets. PPMVs serve as the primary source of malaria treatment for millions of Nigerians. These licensed vendors operate in communities across the country, providing accessible and affordable healthcare services. But if PPMVs stock antimalarials without diagnostic capacity, they become sites of presumptive treatment rather than confirmed diagnosis and appropriate care or treatment.
However, the situation differs markedly in Kano, where testing is commonly found in PPMVs alongside antimalarial drugs. The lower cost of diagnostics makes it economically viable for vendors to offer testing services.
Patients can afford both test and treatment, creating a functional test-and-treat environment even in informal healthcare settings. But some patients in Lagos and Abia are struggling to navigate the pricing gap through strategic choices. They might visit government health facilities where testing is sometimes free or heavily subsidized. But these facilities often face long queues, chalant health workers and limited hours. For someone feeling sick and weak, the convenience of a nearby pharmacy or PPMV outweighs the testing benefit. Others use symptoms to guide their decisions. If they have had malaria before and recognize the signs, they feel confident skipping the test. But malaria symptoms overlap with many other illnesses; fever, headache, and body aches could indicate typhoid, viral infections, or other conditions that need different treatment.
The economic burden falls hardest on low-income families in Nigeria societies. A household budget might stretch to cover either testing or treatment but not both. Parents facing sick children make agonizing choices between proper diagnosis and immediate medication. If there are still middle-class families in Nigeria, they possibly face the same calculation even if the absolute amounts seem smaller.
Young professionals and students represent another affected group. Living on tight budgets in expensive cities like Lagos, they optimize every naira spent. When malaria symptoms strike, the price comparison between testing and treatment drives their healthcare decisions. Many told researchers they would test if it costs less than treatment but right now, the testing is too expensive for them, and they can’t afford it.
The overtreatment problem extends beyond individual health and drug resistance, it wastes limited healthcare resources. Every unnecessary antimalarial dose represents money that could have been spent on actual medical needs. Multiplied across millions of cases, this waste adds up to significant economic losses in the country.
In the same vein, healthcare systems also suffer from the diagnostic gap, because without testing, surveillance data becomes unreliable. Health authorities cannot distinguish between areas with genuine malaria problems and areas where people simply presume they have malaria. This undermines efforts to target interventions effectively. Also, pharmaceutical companies mostly respond to market signals. If most people buy antimalarials without testing, manufacturers focus on drug production rather than diagnostic development. This reduces innovation in testing technology and limits competition that might lower prices.
The testing gap also affects healthcare quality perception, when people take antimalarials and feel better, they credit the drugs even if malaria was not their problem. Many illnesses resolve naturally over a few days, this false correlation reinforces presumptive treatment practices and makes people question why testing is necessary.
Some private healthcare providers have attempted local solutions. A few pharmacies bundle testing with treatment at a package price below the combined individual costs. This pricing structure encourages testing while remaining affordable. But these initiatives remain limited and cannot solve the systemic pricing problem alone.
International health organizations working in Nigeria have recognized the diagnostic gap. Some programmes subsidize RDTs to reduce costs, others train PPMVs in proper testing procedures and provide free or low-cost diagnostic supplies. These interventions show promise but reach only a fraction of the private sector outlets where most Nigerians seek care. The health stakeholders, especially in the rural areas cannot even smell such interventions.
The ACT pricing itself plays a role in the problem. WHO-prequalified and non-prequalified ACTs were similarly priced across all three states surveyed. This uniformity suggests some standardization in the antimalarial market. But no corresponding price standardization exists for diagnostics, leaving them subject to wider variation and often higher costs, especially in Lagos and Abia states.
Subsidy programmes for ACTs have successfully increased access to quality-assured treatment. The Global Fund and other donors support these subsidies to ensure effective antimalarials reach patients at affordable prices. But diagnostic subsidies receive less attention and funding despite being equally essential for proper case management of malaria.
Quality concerns add another dimension to the testing gap. Even when diagnostics are available at reasonable prices, questions arise about their quality and accuracy. Without proper regulation and quality assurance, some providers may stock substandard tests that give false results. This undermines confidence in testing and reinforces guess treatment of malaria.
Training represents another challenge, because using RDTs correctly requires basic training. The user must perform the test properly, interpret results accurately, and explain findings to patients. PPMVs and small pharmacy staff may lack this training, especially in the rural areas, making them reluctant to offer testing services even when economics would support it.
Patient education also matters, as many Nigerians do not understand why testing is important. Public health campaigns have successfully promoted ACT use for malaria treatment, but less emphasis has been placed on explaining the test-before-treat approach. Without this understanding, patients resist paying for tests they view as unnecessary.
The COVID-19 pandemic provided unexpected lessons about diagnostic uptake. When coronavirus emerged, testing became essential despite often costing more than treatment. People learned to accept diagnostic testing as a necessary first step to treatment. This suggests that with proper education and clear messaging or campaign, behaviour change around malaria testing is possible.
Technology might offer some solutions as mobile health platforms and telemedicine services are growing in Nigerian cities. Some companies are exploring ways to integrate malaria testing into their service offerings. If these platforms can achieve the goal and maintain affordable pricing, they might help bridge the testing gap.
In addition, Point-of-care diagnostic technology continues improving in recent years. Newer tests are easier to use, more accurate, and potentially cheaper to manufacture. As these technologies mature and achieve wider distribution, diagnostic costs may naturally decrease. Worrisome still, this market evolution takes time that current patients do not have.
Good or effective policy interventions could accelerate change. State governments in Lagos and Abia could introduce price controls or subsidies for malaria diagnostics. They could mandate that outlets selling antimalarials must also offer testing at regulated prices across the state. But such measures would require careful design to avoid unintended consequences like creating black markets or driving small vendors out of business.
Professional associations representing pharmacists and PPMVs could establish voluntary standards. Members might commit to offering testing at or below treatment costs as a social service. This peer-driven approach could spread best practices while avoiding heavy-handed regulation that might backfire in the long run.
Insurance schemes present another avenue, as health insurance coverage expands in Nigeria, policies could fully cover diagnostic testing while requiring cost-sharing for treatment. This would flip the current incentive structure, making testing the economical choice for malaria patients. However, insurance penetration remains low, limiting this approach’s immediate impact.
Public-private partnerships might mobilize resources and expertise to address the testing gap. The government could partner with diagnostic manufacturers, healthcare providers, and civil society organizations to design comprehensive interventions. These could combine subsidies, training, public education, and quality assurance into integrated programmes.
The evidence from Kano State proves that better outcomes are possible across the country. When diagnostics cost less than treatment, testing becomes standard practice even in informal outlets or rural areas. This model demonstrates that price relationships between testing and treatment fundamentally shape provider and patient behaviour.
Replicating Kano’s success in Lagos and Abia requires understanding what enables the lower diagnostic prices. Is it state-level policies? Different supply chains? Lower overall cost structures? Analyzing these factors could reveal transferable strategies for other states in Nigeria.
Conclusion
The malaria testing gap in Lagos and Abia states exemplifies how pricing structures can undermine public health goals. Well-intentioned people make economically rational decisions that produce collectively harmful outcomes. No individual can be blamed for choosing cheaper drugs over expensive tests when resources are limited.
Solving this problem requires systemic changes that align economic incentives with public health objectives. Diagnostics must become more affordable than treatment for people to be lured into testing. Testing must become the economically obvious choice rather than a luxury for those who can afford extra expenses.
Until these changes occur, millions of Nigerians will continue skipping malaria tests, they will take antimalarials they may not need. Drug resistance will develop faster than it should, while the healthcare resources will be wasted. And the country’s malaria control efforts will be undermined by the very pricing structure that should support them.
The solution is not complicated in concept: Make testing cheaper than treatment, ensure availability matches the need, provide training for proper test use, and educate patients about why testing matters. Furthermore, implementation requires political will, financial resources, and sustained commitment from multiple stakeholders.
The question facing policymakers is clear: Will Nigeria accept the preventable harm caused by pricing diagnostics above treatment? Or will the country invest in making testing the accessible, affordable, obvious first step before any antimalarial is dispensed? The millions who depend on private sector healthcare await the answer.
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